Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Patricia Thomas

Second Advisor

Katherine Moran

Third Advisor

Duncan Howard


Millions of individuals enter correctional facilities each year and require health services. Inmates are bound to a set of rules, wherein they are thought of as objects of surveillance, punishment, or rehabilitation, rather than as patients. In addition to standards of care defined by national accrediting bodies and state boards of practice, correctional facilities also have state laws that define expected health services for incarcerated persons. All health care providers have a responsibility to provide the highest quality care, but in prisons, patients are still inmates bound to correctional rules. Policies and procedures guide health care practices in correctional facilities, but unlike hospitals or other community settings, the state Department of Corrections is not currently affiliated with a single accrediting health care body that sets the benchmarks of quality. Rather, they are expected to meet distinct department of corrections (DOC) regulations in addition to health care accreditation requirements found in primary care, rehabilitation, and hospital level of care. The DOC uses an internal, self-audit process in place of a formal affiliation with external accrediting bodies.

The goal of this project was to evaluate the state Department of Corrections’ (DOC) self-audit process in four facilities, create a cross-map to compare the self-audit tool to accreditation standards of governing healthcare bodies, analyze historic data, and make recommendations for change in the existing tool or realignment with external accrediting bodies. The aim of this project was to conduct a gap analysis of accrediting body standards and the self-audit process to make data-driven, evidence-based recommendations to key stakeholders. The outcome of this evaluation was to recommend that the DOC to re-establish an affiliation with an external accrediting agency.

Additional Files

M. Wideman PP.pdf (740 kB)